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Patel N, Greene N, Guynn N, Sharma A, Toleva O, Mehta PK. Ischemia but no obstructive coronary artery disease: more than meets the eye. Climacteric 2024; 27:22-31. [PMID: 38224068 DOI: 10.1080/13697137.2023.2281933] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 01/16/2024]
Abstract
Symptomatic women with angina are more likely to have ischemia with no obstructive coronary arteries (INOCA) compared to men. In both men and women, the finding of INOCA is not benign and is associated with adverse cardiovascular events, including myocardial infarction, heart failure and angina hospitalizations. Women with INOCA have more angina and a lower quality of life compared to men, but they are often falsely reassured because of a lack of obstructive coronary artery disease (CAD) and a perception of low risk. Coronary microvascular dysfunction (CMD) is a key pathophysiologic contributor to INOCA, and non-invasive imaging methods are used to detect impaired microvascular flow. Coronary vasospasm is another mechanism of INOCA, and can co-exist with CMD, but usually requires invasive coronary function testing (CFT) with provocation testing for a definitive diagnosis. In addition to traditional heart disease risk factors, inflammatory, hormonal and psychological risk factors that impact microvascular tone are implicated in INOCA. Treatment of risk factors and use of anti-atherosclerotic and anti-anginal medications offer benefit. Increasing awareness and early referral to specialized centers that focus on INOCA management can improve patient-oriented outcomes. However, large, randomized treatment trials to investigate the impact on major adverse cardiovascular events (MACE) are needed. In this focused review, we discuss the prevalence, pathophysiology, presentation, diagnosis and treatment of INOCA.
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Affiliation(s)
- N Patel
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - N Greene
- Emory University School of Medicine, Atlanta, GA, USA
| | - N Guynn
- J. Willis Hurst Internal Medicine Residency Program, Emory University, Atlanta, GA, USA
| | - A Sharma
- Department of Internal Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - O Toleva
- Andreas Gruentzig Cardiovascular Center, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - P K Mehta
- Emory Women's Heart Center and Emory Clinical Cardiovascular Research Institute, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
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Adams JA, Uryash A, Lopez JR. Non-Invasive Pulsatile Shear Stress Modifies Endothelial Activation; A Narrative Review. Biomedicines 2022; 10:biomedicines10123050. [PMID: 36551807 PMCID: PMC9775985 DOI: 10.3390/biomedicines10123050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/18/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
The monolayer of cells that line both the heart and the entire vasculature is the endothelial cell (EC). These cells respond to external and internal signals, producing a wide array of primary or secondary messengers involved in coagulation, vascular tone, inflammation, and cell-to-cell signaling. Endothelial cell activation is the process by which EC changes from a quiescent cell phenotype, which maintains cellular integrity, antithrombotic, and anti-inflammatory properties, to a phenotype that is prothrombotic, pro-inflammatory, and permeable, in addition to repair and leukocyte trafficking at the site of injury or infection. Pathological activation of EC leads to increased vascular permeability, thrombosis, and an uncontrolled inflammatory response that leads to endothelial dysfunction. This pathological activation can be observed during ischemia reperfusion injury (IRI) and sepsis. Shear stress (SS) and pulsatile shear stress (PSS) are produced by mechanical frictional forces of blood flow and contraction of the heart, respectively, and are well-known mechanical signals that affect EC function, morphology, and gene expression. PSS promotes EC homeostasis and cardiovascular health. The archetype of inducing PSS is exercise (i.e., jogging, which introduces pulsations to the body as a function of the foot striking the pavement), or mechanical devices which induce external pulsations to the body (Enhanced External Pulsation (EECP), Whole-body vibration (WBV), and Whole-body periodic acceleration (WBPA aka pGz)). The purpose of this narrative review is to focus on the aforementioned noninvasive methods to increase PSS, review how each of these modify specific diseases that have been shown to induce endothelial activation and microcirculatory dysfunction (Ischemia reperfusion injury-myocardial infarction and cardiac arrest and resuscitation), sepsis, and lipopolysaccharide-induced sepsis syndrome (LPS)), and review current evidence and insight into how each may modify endothelial activation and how these may be beneficial in the acute and chronic setting of endothelial activation and microvascular dysfunction.
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Affiliation(s)
- Jose A. Adams
- Division of Neonatology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA
- Correspondence:
| | - Arkady Uryash
- Division of Neonatology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA
| | - Jose R. Lopez
- Department of Research, Mount Sinai Medical Center, Miami Beach, FL 33140, USA
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Adams JA, Uryash A, Lopez JR, Sackner MA. The Endothelium as a Therapeutic Target in Diabetes: A Narrative Review and Perspective. Front Physiol 2021; 12:638491. [PMID: 33708143 PMCID: PMC7940370 DOI: 10.3389/fphys.2021.638491] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 01/29/2021] [Indexed: 12/18/2022] Open
Abstract
Diabetes has reached worldwide epidemic proportions, and threatens to be a significant economic burden to both patients and healthcare systems, and an important driver of cardiovascular mortality and morbidity. Improvement in lifestyle interventions (which includes increase in physical activity via exercise) can reduce diabetes and cardiovascular disease mortality and morbidity. Encouraging a population to increase physical activity and exercise is not a simple feat particularly in individuals with co-morbidities (obesity, heart disease, stroke, peripheral vascular disease, and those with cognitive and physical limitations). Translation of the physiological benefits of exercise within that vulnerable population would be an important step for improving physical activity goals and a stopgap measure to exercise. In large part many of the beneficial effects of exercise are due to the introduction of pulsatile shear stress (PSS) to the vascular endothelium. PSS is a well-known stimulus for endothelial homeostasis, and induction of a myriad of pathways which include vasoreactivity, paracrine/endocrine function, fibrinolysis, inflammation, barrier function, and vessel growth and formation. The endothelial cell mediates the balance between vasoconstriction and relaxation via the major vasodilator endothelial derived nitric oxide (eNO). eNO is critical for vasorelaxation, increasing blood flow, and an important signaling molecule that downregulates the inflammatory cascade. A salient feature of diabetes, is endothelial dysfunction which is characterized by a reduction of the bioavailability of vasodilators, particularly nitric oxide (NO). Cellular derangements in diabetes are also related to dysregulation in Ca2+ handling with increased intracellular Ca2+overload, and oxidative stress. PSS increases eNO bioavailability, reduces inflammatory phenotype, decreases intracellular Ca2+ overload, and increases antioxidant capacity. This narrative review and perspective will outline four methods to non-invasively increase PSS; Exercise (the prototype for increasing PSS), Enhanced External Counterpulsation (EECP), Whole Body Vibration (WBV), Passive Simulated Jogging and its predicate device Whole Body Periodic Acceleration, and will discuss current knowledge on their use in diabetes.
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Affiliation(s)
- Jose A Adams
- Division of Neonatology, Mount Sinai Medical Center, Miami Beach, FL, United States
| | - Arkady Uryash
- Division of Neonatology, Mount Sinai Medical Center, Miami Beach, FL, United States
| | - Jose R Lopez
- Department of Research, Mount Sinai Medical Center, Miami Beach, FL, United States
| | - Marvin A Sackner
- Department of Medicine, Mount Sinai Medical Center, Miami Beach, FL, United States
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Hoong CWS, Tan MLS, Kao SL, Khoo EYH. Effects of external counter-pulsation on endothelial function assessed by peripheral artery tonometry, levels of glycaemia and metabolic markers in individuals with type 2 diabetes mellitus. Diabetes Metab Syndr 2020; 14:2139-2145. [PMID: 33334725 DOI: 10.1016/j.dsx.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 10/13/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS External counter-pulsation (ECP) generates sheer stress thereby improving endothelial function and anginal symptoms in coronary artery disease. Endothelial dysfunction is also involved in the pathogenesis of T2DM. The aim of this pilot study was to investigate the use of ECP at different doses in improving endothelial function and glycaemic markers in T2DM. METHODS This prospective study involved 46 subjects with T2DM randomly assigned to receive 35 sessions of ECP at different regimens (0.5 h versus 1 h) and duration (7 versus 12 weeks). Endothelial function was evaluated by reactive hyperaemia index (RHI) via peripheral arterial tonometry at the start, midpoint and end of study. Other secondary outcomes included fasting glucose, HOMA-IR, HbA1c, blood pressure, lipid profile, weight and vibration sense. RESULTS There was no change in RHI across all 3 regimens of ECP individually or collectively at the end of the study (ΔRHI +0.01%, p = 0.458). Glycaemic markers also remained unchanged at endpoint. Subgroup analysis showed an improvement in RHI (ΔRHI +20.6%, p = 0.0178) in subjects with more severe endothelial dysfunction at baseline. CONCLUSION ECP did not show a beneficial effect on endothelial function or glycemic control in this South-East Asian population with T2DM at any of the three regimens. This may partly be explained by less severe endothelial dysfunction and less insulin resistance in our population at baseline.
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Affiliation(s)
| | - Maudrene Luor Shyuan Tan
- Division of Endocrinology, University Medicine Cluster, National University Health System, Singapore, Singapore
| | - Shih Ling Kao
- Division of Endocrinology, University Medicine Cluster, National University Health System, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Eric Yin Hao Khoo
- Division of Endocrinology, University Medicine Cluster, National University Health System, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Chen Y, Yu H, Zhu J, Zhang H, Zhao Y, Dong Y, Cui Y, Gong G, Chai Q, Guo Y, Liu Z. Low carotid endothelial shear stress associated with cerebral small vessel disease in an older population: A subgroup analysis of a population-based prospective cohort study. Atherosclerosis 2019; 288:42-50. [PMID: 31323461 DOI: 10.1016/j.atherosclerosis.2019.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 06/19/2019] [Accepted: 07/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND AIMS The association between carotid wall shear stress (WSS) and cerebral small vessel disease has yet to be fully elucidated. The major purpose of this study was to investigate this association in older subjects. METHODS Common carotid artery WSS, endothelial function, white matter hyperintensities (WMH), lacunes, and microbleeds were assessed in 1396 older adults. Participants were followed-up for an average of 69.7 months. RESULTS Mean (M) and peak (P) WSS and changes in endothelial function were independently associated with changes in WMH volume and fraction, lacune counts, and microbleed counts (all p < 0.05). The risks of new-incident Fazekas scale ≥2 [hazard ratio (HR) with 95% confidence interval (CI): 2.141 (1.469-3.119), p = 0.005 and 1.731 (1.197-2.505), p = 0.004, respectively], lacunes [HR (95% CI): 2.034 (1.369-3.022), p < 0.001 and 1.693 (1.151-2.490), p = 0.003, respectively], and microbleeds [HR (95% CI): 2.311 (1.509-3.541), p < 0.001 and 2.208 (1.299-3.751), p < 0.001, respectively] were significantly higher in the lowest quartile group than in the higher quartile group, as classified by either MWSS or PWSS, after adjustment for confounders. CONCLUSIONS Low carotid WSS is an independent risk factor for the progression of cerebral small vessel disease in older adults.
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Affiliation(s)
- Yali Chen
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China
| | - Huapeng Yu
- Department of Cardiology, Jinan Institute of Cardiovascular Diseases, The Fourth People's Hospital of Jinan, Jinan, Shandong, 250031, China
| | - Jizheng Zhu
- Emergency Department, The Fourth People's Hospital of Jinan, Jinan, Shandong, 250031, China
| | - Hua Zhang
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China
| | - Yingxin Zhao
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China
| | - Yuanli Dong
- Department of Community, Lanshan District People Hospital, Linyi, Shandong, 276002, China
| | - Yi Cui
- Department of Radiology, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, China
| | - Gary Gong
- The Russel H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA
| | - Qiang Chai
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China
| | - Yuqi Guo
- Key Laboratory of Rare and Uncommon Diseases, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China.
| | - Zhendong Liu
- Cardio-Cerebrovascular Control and Research Center, Institute of Basic Medicine, Shandong Academy of Medical Sciences, Jinan, Shandong, 250062, China.
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Abstract
PURPOSE OF REVIEW Refractory angina (RA), which is characterized by tissue ischemia along with neurological, mitochondrial, and psychogenic dysfunction, is becoming a major cause of morbidity in patients with advanced coronary artery disease. In this review, we discuss in detail the invasive mechanical non-cell therapy-based options, the evidence behind these therapies, and future trends. RECENT FINDINGS There is extensive ongoing research in the areas of spinal-cord stimulation, transmyocardial laser revascularization, sympathectomy, angiogenesis, and other non-cell-based therapies to explore the best therapy for refractory angina. There is conflicting data in the literature suggesting subjective improvement in angina, but very few studies boast improvement in core objective parameters such as myocardial blood flow, survival, or rehospitalizations. Patients with refractory angina are a complex group of patients that need novel approaches to help alleviate their symptoms and reduce mortality. A carefully selected sequence of therapies may provide the best results in this patient population.
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Affiliation(s)
- Amod Amritphale
- Oklahoma University Health Sciences Center, Oklahoma City, OK, USA.
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Badtieva VA, Voroshilova DN. [The implementation of the method of enhanced external counter pulsation for the treatment of cardiovascular diseases]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOĬ FIZICHESKOĬ KULTURY 2018; 95:51-57. [PMID: 29786682 DOI: 10.17116/kurort201895251-57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/17/2022]
Abstract
The cardiovascular diseases occupy a leading place in the structure of overall morbidity affecting the population not only of Russia but also of the majority of the developed countries throughout the world; they thus impose the heavy social and economic burden on both the public healthcare services and the modern society in general. At the same time, systemic atherosclerosis is considered to be one of the most common, severe, and life-threatening condition. Despite the presence of a large number of pharmaceutical and surgical methods for the treatment of this pathology, they are not infrequently lacking the desired effectiveness. The use of the shunting operations and endovascular methods failed to radically resolve the problem of managing systemic atherosclerosis and atherosclerosis of the lower limbs. A relatively novel approach which currently begins to find the ever increasing application for the treatment of patients presenting with cardiovascular pathology is based on the enhanced external counter-pulsation method although both the clinical and theoretical prerequisites of its application were developed rather long ago. This non-invasive therapeutic method allows to increase the perfusion pressure in the coronary arteries in diastole and to reduce the resistance to the cardiac ejection in the systole. The objective of this review article was to perform the analysis of the available literature publications on the use of the enhanced external counter-pulsation technique for the treatment of the patients presenting with the diseases of the cardiovascular system and to evaluate the clinical effectiveness of this approach as well as the availability of the treatment for the patients.
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Affiliation(s)
- V A Badtieva
- Moscow Research and Practical Centre for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Health Department
| | - D N Voroshilova
- Moscow Research and Practical Centre for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Health Department
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Mechanical Therapies for Refractory Angina: The Current Evidence. Am J Ther 2018. [PMID: 29543611 DOI: 10.1097/mjt.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Werner D, Michalk F, Hinz B, Werner U, Voigt JU, Daniel WG. Impact of Enhanced External Counterpulsation on Peripheral Circulation. Angiology 2016; 58:185-90. [PMID: 17495267 DOI: 10.1177/0003319707300013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Enhanced external counterpulsation (EECP) is a noninvasive counterpulsation technique that reduces angina and improves exercise capacity in patients with coronary artery disease. Diastolic coronary perfusion is augmented by pneumatic compression of 3 sets of cuffs wrapped around the lower extremities. Although central hemodynamic changes are well investigated, almost no data exist about the changes of peripheral circulation during EECP. In this study, 12 patients with angina and angiographic evidence of coronary artery disease were treated for 1 hour with EECP. In these patients, peripheral artery disease was excluded by duplex sonography. The patients rested 1 hour before EECP in supine position, and they remained in that position for 1 hour after the procedure. Changes of flow volumes and flow pattern of the posterior tibial artery and the brachial artery were measured by sonography at the end of all 3 periods. Furthermore, we measured the concentration of circulating prostanoids at these 3 time points. Averaged flow volume of the posterior tibial artery decreased to 69% ± 23% (P < .05) during EECP and increased to 133% ± 34% (P < .05) of baseline 1 hour after the procedure. In contrast, the averaged flow volume of the brachial artery increased by 9% ± 4% (P < .05) during EECP and returned to baseline values after EECP. The flow pattern of the posterior tibial artery showed a second early diastolic antegrade flow caused by the cuff inflation and a reverse end-diastolic flow after the deflation of the cuffs. These flow changes caused an increase of the pulsatility index by Gosling (397% during EECP), returning to baseline values in the recovery period. Plasma concentrations of circulating prostanoids showed no significant change during EECP. Thus, pedal flow volume decreased to approximately two thirds of baseline during EECP followed by reactive hyperemia even 1 hour after the procedure; however, this decreased perfusion triggered no change of the prostacyclin/thromboxane ratio and was well tolerated by all investigated patients. The observed 4-fold increase of the peripheral pulsatility index supports the thesis of increase of shear-stress—related improvement of endothelial function during EECP.
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Affiliation(s)
- Dierk Werner
- Department of Cardiology, Helios-Hospital, Schwerin, Germany.
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May O, Søgaard HJ. Enhanced External Counterpulsation Is an Effective Treatment for Depression in Patients With Refractory Angina Pectoris. Prim Care Companion CNS Disord 2015; 17:14m01748. [PMID: 26693035 DOI: 10.4088/pcc.14m01748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 03/30/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To examine the effect of enhanced external counterpulsation (EECP) on depression in patients with refractory angina pectoris (Canadian Cardiovascular Society class 2-4). METHOD The study was a prospective observational investigation with a 2-month control period preceding the EECP therapy (to minimize a possible effect of the regression-toward-the-mean phenomenon). The patients were examined 2 months before and just before EECP and just after, 3 months after, and 12 months after EECP. Depression was assessed using the Major Depression Inventory and the ICD-10. During EECP, 3 sets of cuffs were fastened around the lower extremities and were inflated sequentially to a pressure of 260 mm Hg in each diastole for 60 minutes 5 days a week for 7 weeks (35 sessions). The study was conducted at a regional hospital in Denmark from May 2006 to January 2011. RESULTS Fifty patients with angina pectoris and an abnormal coronary angiography, with no possibility for revascularization, were included (72% men, mean age of 63 years) between May 2006 and January 2011. The prevalence of depression before EECP was 18%, just after was 2%, 3 months after was 2%, and 12 months after was 4% (P = .013). The depressive state was more severe at a lower age (P = .016). No significant predictors of effect of EECP on depression were found (P > .05), and no association was detected between decline in depressive state and chest pain (P > .05). CONCLUSIONS The study indicates that EECP is an effective treatment for depression in patients with refractory angina pectoris, that depression is more severe in younger patients, and that the effect of EECP on depression is not related to the effect on chest pain. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01112163.
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Affiliation(s)
- Ole May
- Cardiovascular Research Unit, Department of Medicine, Regional Hospital West Jutland (Dr May); and Psychiatric Research Unit West, Regional Psychiatric Services West (Dr Søgaard), Herning, Denmark
| | - Hans Jørgen Søgaard
- Cardiovascular Research Unit, Department of Medicine, Regional Hospital West Jutland (Dr May); and Psychiatric Research Unit West, Regional Psychiatric Services West (Dr Søgaard), Herning, Denmark
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Zhang C, Liu X, Wang X, Wang Q, Zhang Y, Ge Z. Efficacy of Enhanced External Counterpulsation in Patients With Chronic Refractory Angina on Canadian Cardiovascular Society (CCS) Angina Class: An Updated Meta-Analysis. Medicine (Baltimore) 2015; 94:e2002. [PMID: 26632696 PMCID: PMC5058965 DOI: 10.1097/md.0000000000002002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A growing number of patients with chronic artery disease suffer from angina, despite the optimal medical management (ie, β-blockers, calcium channel blockers, and long-acting nitrates) and revascularization. Currently, enhanced external counterpulsation (EECP) therapy has been verified as a noninvasive, safe therapy for refractory angina. The study was designed to evaluate the efficacy of EECP in patients with chronic refractory angina according to Canadian Cardiovascular Society (CCS) angina class.We identified systematic literature through MEDLINE, EMBASE, the Cochrane Clinical Trials Register Database, and the ClinicalTrials. gov Website from 1990 to 2015. Studies were considered eligible if they were prospective and reported data on CCS class before and after EECP treatment. Meta-analysis was performed to assess the efficacy of EECP therapy by at least 1 CCS angina class improvement, and proportion along with the 95% confidence interval (CI) was calculated. Statistical heterogeneity was calculated by I statistic and the Q statistic. Sensitivity analysis was addressed to test the influence of trials on the overall pooled results. Subgroup analysis was applied to explore potential reasons for heterogeneity.Eighteen studies were enrolled in our meta-analysis. Pooled analysis showed 85% of patients underwent EECP had a reduction by at least one CCS class (95%CI 0.81-0.88, I = 58.5%, P < 0.001). The proportion of patients enrolled at primarily different studies with chronic heart failure (CHF) improved by at least 1 CCS class was about 84% after EECP (95%CI 0.81-0.88, I = 32.7%, P = 0.1668). After 3 large studies were excluded, the pooled proportion was 82% (95%CI 0.79-0.86, I = 18%, P = 0.2528). Funnel plot indicated that some asymmetry while the Begg and Egger bias statistic showed no publication bias (P = 0.1495 and 0.2859, respectively).Our study confirmed that EECP provided an effective treatment for patients who were unresponsive to medical management and/or invasive therapy. However, the long-term benefits of EECP therapy needed further studies to evaluate in the management of chronic refractory angina.
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Affiliation(s)
- Chunmei Zhang
- From the Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Qilu Hospital of Shandong University, Jinan, Shandong, China
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Macrovascular and microvascular function after implantation of left ventricular assist devices in end-stage heart failure: Role of microparticles. J Heart Lung Transplant 2015; 34:921-32. [PMID: 25980571 DOI: 10.1016/j.healun.2015.03.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 02/08/2015] [Accepted: 03/16/2015] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The hemodynamic vascular consequences of implanting left ventricular assist devices (LVADs) have not been studied in detail. We investigated the effect of LVAD implantation compared with heart transplant (HTx) on microvascular and macrovascular function in patients with end-stage heart failure and evaluated whether microparticles may play a role in LVAD-related endothelial dysfunction. METHODS Vascular function was assessed in patients with end-stage heart failure awaiting HTx, patients who had undergone implantation of a continuous-flow centrifugal LVAD, and patients who had already received a HTx. Macrovascular function was measured by flow-mediated vasodilation (FMD) using high-resolution ultrasound of the brachial artery. Microvascular function was assessed in the forearm during reactive hyperemia using laser Doppler perfusion imaging and pulsed wave Doppler. Age-matched patients without heart failure and without coronary artery disease (CAD) (healthy control subjects) and patients with stable CAD served as control subjects. Circulating red blood cell (CD253(+)), leukocyte (CD45(+)), platelet (CD31(+)/CD41(+)), and endothelial cell (CD31(+)/CD41(-), CD62e(+), CD144(+)) microparticles were determined by flow cytometry and free hemoglobin by enzyme-linked immunosorbent assay. RESULTS FMD and microvascular function were significantly impaired in patients with end-stage heart failure compared with healthy control subjects and patients with stable CAD. LVAD implantation led to recovery of microvascular function, but not FMD. In parallel, increased free hemoglobin was observed along with red and white cell microparticles and endothelial and platelet microparticles. This finding indicates destruction of blood cells with release of hemoglobin and activation of endothelial cells. HTx and LVAD implantation led to similar improvements in microvascular function. FMD increased and microparticle levels decreased in patients with HTx, whereas shear stress during reactive hyperemia was similar in patients with LVADs and patients with HTx. CONCLUSIONS Our data suggest that LVAD support leads to significant improvements in microvascular perfusion and hemodynamics. However, destruction of blood cells may contribute to residual endothelial dysfunction potentially by increasing nitric oxide scavenging capacity.
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 2014; 149:e5-23. [PMID: 25827388 DOI: 10.1016/j.jtcvs.2014.11.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Circulation 2014; 130:1749-67. [DOI: 10.1161/cir.0000000000000095] [Citation(s) in RCA: 388] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929-49. [PMID: 25077860 DOI: 10.1016/j.jacc.2014.07.017] [Citation(s) in RCA: 554] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Usefulness of brachial artery flow-mediated dilation to predict long-term cardiovascular events in subjects without heart disease. Am J Cardiol 2014; 113:162-7. [PMID: 24169007 DOI: 10.1016/j.amjcard.2013.08.051] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 01/07/2023]
Abstract
Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. To determine the long-term association of brachial artery flow-mediated dilation (FMD) and adverse cardiovascular (CV) events in healthy subjects, we prospectively assessed brachial FMD in 618 consecutive healthy subjects with no apparent heart disease, 387 men (63%), and mean age 54 ± 11 years. After overnight fasting and discontinuation of all medications for ≥12 hours, FMD was assessed using high-resolution linear array ultrasound. Subjects were divided into 2 groups: FMD ≤11.3% (n = 309) and >11.3% (n = 309), where 11.3% is the median FMD, and were comparable regarding CV risk factors, lipoproteins, fasting glucose, C-reactive protein, concomitant medications, and Framingham 10-year risk score. In a mean clinical follow-up of 4.6 ± 1.8 years, the composite CV events (all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions) were significantly more common in subjects with FMD ≤11.3% rather than >11.3% (15.2% vs 1.2%, p = 0.0001, respectively). Univariate analysis demonstrated that the median FMD significantly predicted CV events (odds ratio 2.78, 95% CI 1.35 to 5.71, p <0.001). Multivariate analysis, controlling for traditional CV risk factors, demonstrated that median FMD was the best independent predictor of long-term CV adverse events (odds ratio 2.93, 95% CI 1.28 to 6.68, p <0.001). In conclusion, brachial artery median FMD independently predicts long-term adverse CV events in healthy subjects with no apparent heart disease in addition to those derived from traditional risk factor assessment.
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Abstract
Enhanced external counterpulsation (EECP) has been approved by the United States Food and Drug Administration (FDA) for management of refractory angina (Class IIb). EECP uses three sets of pneumatic cuffs that sequentially contract during diastole, increasing aortic diastolic pressure, augmenting coronary blood flow and central venous return. EECP improves anginal symptoms and exercise tolerance, and reduces nitroglycerin use in patients with chronic, stable angina. EECP has also been shown to be safe and beneficial in patients with symptomatic stable congestive heart failure. It has been postulated that cardiac benefits of EECP are mediated though vascular endothelial growth factor (VEGF) and nitric oxide mediated vasodilatation and angiogenesis. In June 2002, the FDA also approved EECP therapy for heart failure patients.
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Affiliation(s)
- Umesh Sharma
- Corresponding Author: Tahir Tak, FACC; Division of Cardiovascular Services; Mayo Clinic; 200 First Street, SW; Rochester, MN 55905; .
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Early Enhanced External Counter Pulsation Improves Neurological Recovery After the Return of Spontaneous Circulation in a Mongrel Dog Cardiac Arrest Model*. Crit Care Med 2013; 41:e62-73. [DOI: 10.1097/ccm.0b013e318278b469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wu E, Mårtensson J, Broström A. Enhanced external counterpulsation in patients with refractory angina pectoris: a pilot study with six months follow-up regarding physical capacity and health-related quality of life. Eur J Cardiovasc Nurs 2012; 12:437-45. [DOI: 10.1177/1474515112468067] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Eline Wu
- Department of Cardiology M82, Karolinska University Hospital, Sweden
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012. [PMID: 23182125 DOI: 10.1016/j.jacc.2012.07.013] [Citation(s) in RCA: 1231] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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21
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Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV, Anderson JL. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2012; 126:e354-471. [PMID: 23166211 DOI: 10.1161/cir.0b013e318277d6a0] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Flammer AJ, Anderson T, Celermajer DS, Creager MA, Deanfield J, Ganz P, Hamburg NM, Lüscher TF, Shechter M, Taddei S, Vita JA, Lerman A. The assessment of endothelial function: from research into clinical practice. Circulation 2012; 126:753-67. [PMID: 22869857 DOI: 10.1161/circulationaha.112.093245] [Citation(s) in RCA: 827] [Impact Index Per Article: 68.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Andreas J Flammer
- Division of Cardiovascular Diseases, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
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Al Kaabi A, Traupe T, Stutz M, Buchs N, Heller M. Cause or effect of arteriogenesis: compositional alterations of microparticles from CAD patients undergoing external counterpulsation therapy. PLoS One 2012; 7:e46822. [PMID: 23056467 PMCID: PMC3466210 DOI: 10.1371/journal.pone.0046822] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 09/05/2012] [Indexed: 01/04/2023] Open
Abstract
Recently, a clinical study on patients with stable coronary artery disease (CAD) showed that external counterpulsation therapy (ECP) at high (300 mmHg) but not at low inflation pressure (80 mmHg) promoted coronary collateral growth, most likely due to shear stress-induced arteriogenesis. The exact molecular mechanisms behind shear stress-induced arteriogenesis are still obscure. We therefore characterized plasma levels of circulating microparticles (MPs) from these CAD patients because of their ambivalent nature as a known cardiovascular risk factor and as a promoter of neovascularization in the case of platelet-derived MPs. MPs positive for Annexin V and CD31CD41 were increased, albeit statistically significant (P<0.05, vs. baseline) only in patients receiving high inflation pressure ECP as determined by flow cytometry. MPs positive for CD62E, CD146, and CD14 were unaffected. In high, but not in low, inflation pressure treatment, change of CD31CD41 was inversely correlated to the change in collateral flow index (CFI), a measure for collateral growth. MPs from the high inflation pressure group had a more sustained pro-angiogenic effect than the ones from the low inflation pressure group, with the exception of one patient showing also an increased CFI after treatment. A total of 1005 proteins were identified by a label-free proteomics approach from MPs of three patients of each group applying stringent acceptance criteria. Based on semi-quantitative protein abundance measurements, MPs after ECP therapy contained more cellular proteins and increased CD31, corroborating the increase in MPs. Furthermore, we show that MP-associated factors of the innate immune system were decreased, many membrane-associated signaling proteins, and the known arteriogenesis stimulating protein transforming growth factor beta-1 were increased after ECP therapy. In conclusion, our data show that ECP therapy increases platelet-derived MPs in patients with CAD and that the change in protein cargo of MPs is likely in favor of a pro angiogenic/arteriogenic property.
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Affiliation(s)
- Ali Al Kaabi
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Tobias Traupe
- Department of Cardiology, University Hospital Bern, Bern, Switzerland
| | - Monika Stutz
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Natasha Buchs
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Manfred Heller
- Department of Clinical Research, University of Bern, Bern, Switzerland
- * E-mail:
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May O, Khair WAM. Enhanced external counterpulsation has no lasting effect on ambulatory blood pressure. Clin Cardiol 2012; 36:21-4. [PMID: 22886748 DOI: 10.1002/clc.22045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 07/10/2012] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Enhanced external counterpulsation (EECP) has been reported to reduce blood pressure (BP) using clinic BP readings. The aim of this study was to assess the effect of a course of EECP on BP using ambulatory BP (ABP) measurements. HYPOTHESIS EECP has a lasting BP lowering effect. METHODS Patients referred for EECP due to refractory angina pectoris were consecutively included in the study. The ABPs were measured for 24 hours using a Spacelabs Ultralite 90217 device at 5 time points during the study period: 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP. Antihypertensive medication was held constant during the study period. Changes in BP were tested by repeated measures analysis. RESULTS Fifty patients were included in the study. The mean age was 63 years, and 72% were male. The Canadian Cardiovascular Society Angina Grading Scale class improved from a mean of 2.6 to 1.5. The mean daytime ABPs were 114/69, 114/70, 115/71, 114/70, and 116/71 mm Hg and the mean nighttime ABPs were 107/63, 108/63, 106/62, 108/63, and 107/62 mm Hg at 2 months before the EECP course, just before the EECP course, just after the EECP course, and at 3 and 12 months after EECP, respectively (all P > 0.10). Further, when controlling for quartiles of baseline ABP level, no significant change in ABP was found. CONCLUSIONS Enhanced external counterpulsation treatment has no lasting effect on ABP.
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Affiliation(s)
- Ole May
- Cardiovascular Research Unit, Department of Medicine, Region Hospital Herning, Herning, Denmark.
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25
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Yang DY, Wu GF. Vasculoprotective properties of enhanced external counterpulsation for coronary artery disease: beyond the hemodynamics. Int J Cardiol 2012; 166:38-43. [PMID: 22560950 DOI: 10.1016/j.ijcard.2012.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2011] [Revised: 02/22/2012] [Accepted: 04/01/2012] [Indexed: 11/16/2022]
Abstract
A growing pool of evidence has shown that enhanced external counterpulsation (EECP) is a non-invasive, safe, low-cost, and highly beneficial therapy for patients with coronary artery disease. However, the exact mechanisms of benefit exerted by EECP therapy remain only partially understood. The favorable hemodynamic effects of EECP were previously considered as the primary mechanism of action. Nevertheless, recent advances have shed light on the shear stress-increasing effects of EECP which are vasculoprotective and anti-atherosclerotic. EECP-induced endothelial shear stress increase may lead to improvement in endothelial function and morphology, attenuation of oxidative stress and inflammation, and promotion of angiogenesis and vasculogenesis. This review summarizes evidence of the potential mechanisms contributing to the immediate and long-term benefits of EECP, from the perspective of its shear stress-increasing effects.
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Affiliation(s)
- Da-ya Yang
- Division of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, China
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Stoner L, McCully KK. Velocity acceleration as a determinant of flow-mediated dilation. ULTRASOUND IN MEDICINE & BIOLOGY 2012; 38:580-592. [PMID: 22342687 DOI: 10.1016/j.ultrasmedbio.2011.12.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Revised: 12/09/2011] [Accepted: 12/28/2011] [Indexed: 05/31/2023]
Abstract
Shear stress is the established stimulus for flow-mediated dilation (FMD). In vivo, shear stress is typically estimated using mean blood velocity. However, mean blood velocity may not adequately characterize the shear stimulus. Pulsatile flow results in large shear gradients (velocity acceleration) at the onset of flow. The purpose of this study was to determine the importance of velocity acceleration to FMD. We define FMD as the brachial artery shear rate-diameter slope. Fourteen physically active, young (26 ± 5 years), male subjects were tested. Progressive forearm heating and handgrip exercise elicited steady-state increases in shear rate. FMD was measured prior to and following induced increases in velocity acceleration. Velocity acceleration was increased by inflating a tourniquet around the forearm to 40 mm Hg. Hierarchical linear modeling was used to estimate change in diameter with repeated measures of shear stress nested within each subject. Averaged across conditions, the 40 mm Hg cuff resulted in a 14% increase in velocity acceleration (p = 0.001). FMD was attenuated by 11.0% (p = 0.015) for the acceleration vs. control condition. However, after specifying velocity acceleration as a covariate, FMD was no longer significantly (p = 0.619) different between acceleration and control conditions. This finding suggests that mean blood velocity alone may not adequately characterize the shear stimulus.
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Affiliation(s)
- Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, New Zealand.
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27
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Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines. Can J Cardiol 2012; 28:S20-41. [DOI: 10.1016/j.cjca.2011.07.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/24/2022] Open
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Stoner L, Sabatier MJ. Use of ultrasound for non-invasive assessment of flow-mediated dilation. J Atheroscler Thromb 2012; 19:407-21. [PMID: 22659525 DOI: 10.5551/jat.11395] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The pathological complications of atherosclerosis, namely heart attacks and strokes, remain the leading cause of mortality in the Western world. Preceding atherosclerosis is endothelial dysfunction. There is therefore interest in the application of non-invasive clinical tools to assess endothelial function. The flow-mediated dilation (FMD) test is the standard tool used to assess endothelial function. Reduced FMD is an early marker of atherosclerosis and has been noted for its capacity to predict future cardiovascular disease events. This review discusses the measurement of endothelial function using ultrasound, with a focus on the FMD technique.
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Affiliation(s)
- Lee Stoner
- School of Sport and Exercise, Massey University, Wellington, New Zealand.
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29
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The importance of velocity acceleration to flow-mediated dilation. Int J Vasc Med 2012; 2012:589213. [PMID: 22315688 PMCID: PMC3270398 DOI: 10.1155/2012/589213] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/12/2011] [Indexed: 01/22/2023] Open
Abstract
The validity of the flow-mediated dilation test has been questioned due to the lack of normalization to the primary stimulus, shear stress. Shear stress can be calculated using Poiseuille's law. However, little attention has been given to the most appropriate blood velocity parameter(s) for calculating shear stress. The pulsatile nature of blood flow exposes the endothelial cells to two distinct shear stimuli during the cardiac cycle: a large rate of change in shear at the onset of flow (velocity acceleration), followed by a steady component. The parameter typically entered into the Poiseuille's law equation to determine shear stress is time-averaged blood velocity, with no regard for flow pulsatility. This paper will discuss (1) the limitations of using Posieuille's law to estimate shear stress and (2) the importance of the velocity profile-with emphasis on velocity acceleration-to endothelial function and vascular tone.
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30
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Bart BA. EECP. Coron Artery Dis 2012. [DOI: 10.1007/978-1-84628-712-1_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Shechter M, Shechter A, Hod H, Fefer P, Shenkman B, Koren-Morag N, Feinberg MS, Harats D, Ami Sela B, Savion N, Varon D, Matetzky S. Brachial artery endothelial function predicts platelet function in control subjects and in patients with acute myocardial infarction. Platelets 2011; 23:202-10. [PMID: 21824040 DOI: 10.3109/09537104.2011.604805] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Platelet activation occurs in an endothelium-dependent flow-mediated dilation (FMD) impairment environment. The aim of this study was to explore the association between platelet reactivity and brachial artery FMD in individuals without established cardiovascular disease (controls) and acute myocardial infarction (AMI) patients. We prospectively assessed brachial artery FMD in 151 consecutive subjects, 104 (69%) controls, and 47 (31%) AMI patients; 115 (76%) men, mean age 53 ± 11 years. Following overnight fasting and discontinuation of all medications for ≥ 12 h, percent change in brachial artery FMD (%FMD) and endothelium-independent, nitroglycerin-mediated vasodilation (%NTG) were assessed. Platelet aggregation was assessed by conventional aggregometry, and platelet adhesion and aggregation under flow conditions by cone-and-plate(let) technology (Impact-R). Smoking, diabetes, and hypertension were more common in AMI compared to control subjects (p < 0.01 for all). Furthermore, aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors, and statin administration were more common in AMI compared to controls (p < 0.01 for all). %FMD but not %NTG was significantly lower in AMI patients compared to controls (10.2 ± 4.2% vs. 15.4 ± 4.4%; p < 0.001 and 17.2 ± 3.9% vs. 18.0 ± 3.7%, p = 0.803, respectively). %FMD was significantly and inversely associated with all platelet functions tests (p < 0.001) in all study participants. In a multivariate logistic regression (unadjusted and adjusted for age, gender, smoking status, diabetes mellitus, hypertension, hypercholesterolemia, overweight, family history, and concomitant medications), %FMD remained the best predictor of platelet function, irrespective of group allocation (AMI patients or controls). In conclusion, FMD is inversely correlated to platelet reactivity in both controls and AMI patients.
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Affiliation(s)
- Michael Shechter
- Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Casey DP, Beck DT, Nichols WW, Conti CR, Choi CY, Khuddus MA, Braith RW. Effects of enhanced external counterpulsation on arterial stiffness and myocardial oxygen demand in patients with chronic angina pectoris. Am J Cardiol 2011; 107:1466-72. [PMID: 21420062 DOI: 10.1016/j.amjcard.2011.01.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Revised: 01/11/2011] [Accepted: 01/11/2011] [Indexed: 01/27/2023]
Abstract
Enhanced external counterpulsation (EECP) is a noninvasive technique for treatment of symptomatic coronary artery disease in patients not amenable to revascularization procedures. However, the mechanisms underlying the benefits of EECP remain unknown. We hypothesized that decreases in arterial stiffness and aortic wave reflection are a therapeutic target for EECP. Patients with coronary artery disease and chronic angina pectoris were randomized (2:1 ratio) to 35 1-hour sessions of EECP (n = 28) or sham EECP (n = 14). Central and peripheral arterial pulse-wave velocity and aortic wave reflection (augmentation index) were measured using applanation tonometry before, and after 17 and 35 1-hour treatment sessions. Wasted left ventricular pressure energy and aortic systolic tension-time index, markers of left-ventricular myocardial oxygen demand, were derived from the synthesized aortic pressure wave. Exercise duration, anginal threshold, and peak oxygen consumption were measured using a graded treadmill test. Central arterial stiffness and augmentation index were decreased after 17 and 35 sessions in the treatment group. Measurements of peripheral arterial stiffness were decreased after 35 sessions in the treatment group. Changes in aortic pressure wave reflection resulted in decreased measurements of myocardial oxygen demand and wasted left ventricular energy. No changes in central or peripheral arterial stiffness were observed in the sham group. Furthermore, measurements of exercise capacity were improved in the EECP group but unchanged in the sham group. In conclusion, EECP therapy decreases central and peripheral arterial stiffness, which may explain improvements in myocardial oxygen demand in patients with chronic angina pectoris after treatment.
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Shechter M, Shalmon G, Scheinowitz M, Koren-Morag N, Feinberg MS, Harats D, Sela BA, Sharabi Y, Chouraqui P. Impact of acute caffeine ingestion on endothelial function in subjects with and without coronary artery disease. Am J Cardiol 2011; 107:1255-61. [PMID: 21349479 DOI: 10.1016/j.amjcard.2010.12.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 12/21/2010] [Accepted: 12/21/2010] [Indexed: 11/17/2022]
Abstract
Although coffee is a widely used, pharmacologically active beverage, its impact on the cardiovascular system is controversial. To explore the effect of acute caffeine ingestion on brachial artery flow-mediated dilation (FMD) in subjects without coronary artery disease (CAD; controls) and patients with CAD, we prospectively assessed brachial artery FMD in 40 controls and 40 age- and gender-matched patients with documented stable CAD on 2 separate mornings 1 week to 2 weeks apart. After overnight fasting, discontinuation of all medications for ≥12 hours, and absence of caffeine for >48 hours, participants received capsules with caffeine 200 mg or placebo. One hour after drug ingestion, participants underwent brachial artery FMD and nitroglycerin-mediated dilation (NTG) using high-resolution ultrasound. As expected, patients with CAD were more often diabetic, hypertensive, obese, dyslipidemic, and smoked more than controls (p <0.01 for all comparisons). Aspirin, Clopidogrel, angiotensin-converting enzyme inhibitors, β blockers, and statins were significantly more common in patients with CAD than in controls (p <0.01 for all comparisons). At baseline, FMD, but not NTG, was significantly lower in patients with CAD compared to controls. Acute caffeine ingestion significantly increased FMD (patients with CAD 5.6 ± 5.0% vs 14.6 ± 5.0%, controls 8.4 ± 2.9% vs 18.6 ± 6.8%, p <0.001 for all comparisons) but not NTG (patients with CAD 13.0 ± 5.2% vs 13.8 ± 6.1%, controls 12.9 ± 3.9% vs 13.9 ± 5.8%, p = NS for all comparisons) and significantly decreased high-sensitivity C-reactive protein (patients with CAD 2.6 ± 1.4 vs 1.4 ± 1.2 mg/L, controls 3.4 ± 3.0 vs 1.2 ± 1.0 mg/L, p <0.001 for all comparisons) in the 2 groups compared to placebo. In conclusion, acute caffeine ingestion significantly improved endothelial function assessed by brachial artery FMD in subjects with and without CAD and was associated with lower plasma markers of inflammation.
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Affiliation(s)
- Michael Shechter
- Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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Beigel R, Dvir D, Arbel Y, Shechter A, Feinberg MS, Shechter M. Pulse pressure is a predictor of vascular endothelial function in middle-aged subjects with no apparent heart disease. Vasc Med 2010; 15:299-305. [PMID: 20724375 DOI: 10.1177/1358863x10373300] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Elevated pulse pressure (PP) is increasingly being recognized as a cardiovascular risk factor. To investigate whether PP is associated with endothelial function in subjects with no apparent heart disease we prospectively assessed brachial flow-mediated dilation (FMD) in 525 consecutive subjects with no apparent heart disease [323 (61%) men, mean age 52 +/- 11 years, mean body mass index (BMI) 26 +/- 4 kg/m(2)]. Following an overnight fast and discontinuation of all medications for >/= 12 hours, the FMD and endothelium-independent, nitroglycerin-mediated vasodilation (NTG) were assessed using high-resolution linear array ultrasound. Univariate linear analysis revealed a significant inverse association between FMD and PP (r = -0.65, p < 0.01), systolic blood pressure (r = -0.52, p < 0.01) and age (r = -0.21, p < 0.05). Multivariate analysis showed that PP was the strongest independent predictor of FMD. We therefore divided the study population into two groups: group A (n = 290) </= the median PP, and group B (n = 235) > the median PP of 50 mmHg. Male sex, hypertension, diabetes, BMI, heart rate, and the use of aspirin, long-acting nitrates, calcium channel blockers, angiotensin-converting enzyme inhibitors and beta blockers were significantly more common in Group B compared with Group A. FMD but not NTG was significantly greater in patients with PP </= the median PP, compared with > the median PP (14.9 +/- 7.9% vs 10.8 +/- 8.8%, p < 0.001 and 16.1 +/- 9.6% vs 14.8 +/- 8.4%, p = 0.38; respectively). Thus, PP is inversely associated with brachial FMD in middle-aged subjects with no apparent heart disease, suggesting a potential mechanism whereby elevated PP contributes to cardiovascular disease. Long-term follow-up is warranted to elucidate the incidence of coronary artery disease in both study groups.
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Affiliation(s)
- Roy Beigel
- Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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Braith RW, Conti CR, Nichols WW, Choi CY, Khuddus MA, Beck DT, Casey DP. Enhanced external counterpulsation improves peripheral artery flow-mediated dilation in patients with chronic angina: a randomized sham-controlled study. Circulation 2010; 122:1612-20. [PMID: 20921442 DOI: 10.1161/circulationaha.109.923482] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Mechanisms responsible for anti-ischemic benefits of enhanced external counterpulsation (EECP) remain unknown. This was the first randomized sham-controlled study to investigate the extracardiac effects of EECP on peripheral artery flow-mediated dilation. METHODS AND RESULTS Forty-two symptomatic patients with coronary artery disease were randomized (2:1 ratio) to thirty-five 1-hour sessions of either EECP (n=28) or sham EECP (n=14). Flow-mediated dilation of the brachial and femoral arteries was performed with the use of ultrasound. Plasma levels of nitrate and nitrite, 6-keto-prostaglandin F(1α), endothelin-1, asymmetrical dimethylarginine, tumor necrosis factor-α, monocyte chemoattractant protein-1, soluble vascular cell adhesion molecule, high-sensitivity C-reactive protein, and 8-isoprostane were measured. EECP increased brachial (+51% versus +2%) and femoral (+30% versus +3%) artery flow-mediated dilation, the nitric oxide turnover/production markers nitrate and nitrite (+36% versus +2%), and 6-keto-prostaglandin F(1α) (+71% versus +1%), whereas it decreased endothelin-1 (-25% versus +5%) and the nitric oxide synthase inhibitor asymmetrical dimethylarginine (-28% versus +0.2%) in treatment versus sham groups, respectively (all P<0.05). EECP decreased the proinflammatory cytokines tumor necrosis factor-α (-16% versus +12%), monocyte chemoattractant protein-1 (-13% versus +0.2%), soluble vascular cell adhesion molecule-1 (-6% versus +1%), high-sensitivity C-reactive protein (-32% versus +5%), and the lipid peroxidation marker 8-isoprostane (-21% versus +1.3%) in treatment versus sham groups, respectively (all P<0.05). EECP reduced angina classification (-62% versus 0%; P<0.001) in treatment versus sham groups, respectively. CONCLUSIONS Our findings provide novel mechanistic evidence that EECP has a beneficial effect on peripheral artery flow-mediated dilation and endothelial-derived vasoactive agents in patients with symptomatic coronary artery disease.
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Affiliation(s)
- Randy W Braith
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA.
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Hirsch L, Shechter A, Feinberg MS, Koren-Morag N, Shechter M. The impact of early compared to late morning hours on brachial endothelial function and long-term cardiovascular events in healthy subjects with no apparent coronary heart disease. Int J Cardiol 2010; 151:342-7. [PMID: 20832878 DOI: 10.1016/j.ijcard.2010.08.069] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 07/14/2010] [Accepted: 08/19/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adverse cardiovascular events (CVE) tend to peak during early morning post-waking hours. Our objective was to explore a possible correlation between early and late morning hours and flow-mediated dilation (FMD), and whether early morning FMD reduction contributes to a circadian pattern of cardiac and vascular vulnerability. METHODS Brachial FMD was prospectively assessed in 268 consecutive healthy subjects, 169 (63%) men, mean age 53 ± 11 years, without any concomitant medications. Following an overnight fast, FMD and endothelium-independent nitroglycerin-mediated vasodilation were assessed using high-resolution ultrasound. All subjects were followed up by phone every 6 months for combined CVE, which included all-cause mortality, myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting and percutaneous coronary interventions. RESULTS The cohort was divided into Group A with FMD performed immediately post-waking, between 6:00 and 10:00 am [n=151 (56%) subjects], and Group B after 10:00 am [n=117 (46%) subjects]. Although both groups were comparable regarding baseline brachial artery diameter and the prevalence of risk factors, FMD was significantly lower in Group A compared with Group B subjects (10.4 ± 3.4% vs. 13.5 ± 3.5%, p=0.007, respectively). In a mean follow-up of 45 ± 21 months, the composite CVEs were significantly more common in subjects with ≤(n=128) vs. >(n=140) the median FMD of 11.3% [18/128 (14.1%) vs. 1/140 (0.7%), p=0.007, respectively]. Furthermore, FMD independently predicted long-term adverse CVE. CONCLUSIONS FMD is blunted in early compared to late morning post-waking hours, and independently predicts long-term adverse CVE in healthy subjects with no apparent heart disease.
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Affiliation(s)
- Liran Hirsch
- Leviev Heart Center, Chaim Sheba Medical Center, Tel Hashomer, Israel
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Shimizu T, Kyo S, Imanaka K, Nakaoka K, Nishimura E, Okumura T, Ishii M, Hisagi M, Nishimura T, Motomura N, Ono M, Takamoto S. A novel external counterpulsation system for coronary artery disease and heart failure: pilot studies and initial clinical experiences. J Artif Organs 2010; 13:161-9. [PMID: 20737280 DOI: 10.1007/s10047-010-0511-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 07/19/2010] [Indexed: 11/25/2022]
Abstract
External counterpulsation (ECP) is a beneficial and noninvasive treatment for coronary artery disease or heart failure; however, it still has a lot of limitations. We used a novel ECP system, Compact CP, the main feature of which is the double-lumen cuff that reduces the impact of cuff inflation and the size of the air compressor. The first lumen was a contact cuff that was attached to the legs with a constant pressure (8 kPa). The second lumen was a main cuff that was inflated and deflated with a driving pressure and synchronized to the cardiac cycle. In this report, we describe the results of four pilot studies in a total number of 39 healthy volunteers and initial clinical experiences of this system in three patients. The pilot studies demonstrated that the ECP system provided significant diastolic augmentation and systolic unloading. It also achieved a satisfactory diastolic/systolic pressure ratio (1.00 ± 0.06) with a high comfort level at a driving pressure of 40 kPa. Higher pressure (50-70 kPa) increased the assist performance but decreased the comfort level. ECP was also applied with a patient with chronic refractory angina and two patients with postoperative heart failure following cardiac surgery. The clinical conditions improved. No adverse effect was observed. Our novel ECP system is safe, effective, and promising in the treatment of coronary artery disease or heart failure. Further clinical investigations are needed to support the significance of this system.
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Affiliation(s)
- Tsuyoshi Shimizu
- Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Shah SA, Shapiro RJ, Mehta R, Snyder JA. Impact of Enhanced External Counterpulsation on Canadian Cardiovascular Society Angina Class in Patients with Chronic Stable Angina: A Meta-analysis. Pharmacotherapy 2010; 30:639-45. [DOI: 10.1592/phco.30.7.639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Lavi T, Karasik A, Koren-Morag N, Kanety H, Feinberg MS, Shechter M. The Acute Effect of Various Glycemic Index Dietary Carbohydrates on Endothelial Function in Nondiabetic Overweight and Obese Subjects. J Am Coll Cardiol 2009; 53:2283-7. [DOI: 10.1016/j.jacc.2009.03.025] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 02/18/2009] [Accepted: 03/03/2009] [Indexed: 11/26/2022]
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Uryash A, Wu H, Bassuk J, Kurlansky P, Sackner MA, Adams JA. Low-amplitude pulses to the circulation through periodic acceleration induces endothelial-dependent vasodilatation. J Appl Physiol (1985) 2009; 106:1840-7. [PMID: 19325024 DOI: 10.1152/japplphysiol.91612.2008] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Low-amplitude pulses to the vasculature increase pulsatile shear stress to the endothelium. This activates endothelial nitric oxide (NO) synthase (eNOS) to promote NO release and endothelial-dependent vasodilatation. Descent of the dicrotic notch on the arterial pulse waveform and a-to-b ratio (a/b; where a is the height of the pulse amplitude and b is the height of the dicrotic notch above the end-diastolic level) reflects vasodilator (increased a/b) and vasoconstrictor effects (decreased a/b) due to NO level change. Periodic acceleration (pG(z)) (motion of the supine body head to foot on a platform) provides systemic additional pulsatile shear stress. The purpose of this study was to determine whether or not pG(z) applied to rats produced endothelial-dependent vasodilatation and increased NO production, and whether the latter was regulated by the Akt/phosphatidylinositol 3-kinase (PI3K) pathway. Male rats were anesthetized and instrumented, and pG(z) was applied. Sodium nitroprusside, N(G)-nitro-l-arginine methyl ester (l-NAME), and wortmannin (WM; to block Akt/PI3K pathway) were administered to compare changes in a/b and mean aortic pressure. Descent of the dicrotic notch occurred within 2 s of initiating pG(z). Dose-dependent increase of a/b and decrease of mean aortic pressure took place with SNP. l-NAME produced a dose-dependent rise in mean aortic pressure and decrease of a/b, which was blunted with pG(z). In the presence of WM, pG(z) did not decrease aortic pressure or increase a/b. WM also abolished the pG(z) blunting effect on blood pressure and a/b of l-NAME-treated animals. eNOS expression was increased in aortic tissue after pG(z). This study indicates that addition of low-amplitude pulses to circulation through pG(z) produces endothelial-dependent vasodilatation due to increased NO in rats, which is mediated via activation of eNOS, in part, by the Akt/PI3K pathway.
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Affiliation(s)
- Arkady Uryash
- Deptartment of Research, Mt. Sinai Medical Center, Miami Beach, FL 33410, USA
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Hashemi M, Hoseinbalam M, Khazaei M. Long-term effect of enhanced external counterpulsation on endothelial function in the patients with intractable angina. Heart Lung Circ 2008; 17:383-7. [PMID: 18706862 DOI: 10.1016/j.hlc.2008.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2007] [Revised: 02/04/2008] [Accepted: 02/06/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Enhanced external counterpulsation (EECP) is a noninvasive, pneumatic technique that provides favourable effects in patients with coronary artery disease. The objective of this study was to describe the long-term effect of EECP on endothelial function in patients with ischaemic cardiomyopathy. METHOD The study was performed in 15 patients with ischaemic cardiomyopathy. All subjects were treated with EECP 1-h per day, 5 days a week, over 7 weeks (totally 35h). Endothelium-dependent and -independent relaxation was assessed by flow-mediated dilation (FMD) and nitroglycerine-mediated dilatation (NMD). In each patient, FMD and NMD measurements were performed before, at midcourse (day 17th) and after completion of EECP course (day 35th). In addition, FMD index was assessed 1 month after completion of EECP therapy. RESULTS Results showed that EECP was associated with a significant improvement in FMD index after 35 hours of EECP (10.95+/-4.1% vs. 7.40+/-4.9% for baseline, p<0.05). NMD index didn't significantly alter during the EECP therapy. Also, 1 month after completion of EECP, FMD index returned to baseline (7.51+/-4.4% vs. 7.40+/-4.9%, respectively, p<0.05). EECP acutely improved endothelial function in ischaemic cardiomyopathic patients. However, after 1 month completion of treatment, endothelium-dependent vasorelaxation returned to baseline. CONCLUSION It seems that improvement of endothelial function is not the main mechanism of long-term EECP treatment and other mechanisms should be considered.
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Affiliation(s)
- Mohammad Hashemi
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Shechter M, Issachar A, Marai I, Koren-Morag N, Freinark D, Shahar Y, Shechter A, Feinberg MS. Long-term association of brachial artery flow-mediated vasodilation and cardiovascular events in middle-aged subjects with no apparent heart disease. Int J Cardiol 2008; 134:52-8. [PMID: 18479768 DOI: 10.1016/j.ijcard.2008.01.021] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Revised: 12/20/2007] [Accepted: 01/11/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. The aim of this study was to detect the long-term association of peripheral vascular endothelial function and clinical outcome in healthy subjects without apparent coronary artery disease (CAD). METHODS We prospectively assessed brachial flow-mediated dilation (FMD) in 435 consecutive healthy subjects: 281 (65%) men, mean age 54+/-12 years and body mass index 28+/-4 kg/m(2). After overnight fasting and discontinuation of all medications for > or =12 h, FMD and endothelium-independent nitroglycerin-mediated vasodilation were assessed using high resolution linear array ultrasound. RESULTS Subjects were divided into 2 groups: below (n=221) and above (n=214) the median FMD of 10.7%, and were comparable regarding CAD risk factors, lipoproteins, fasting glucose, C-reactive protein, and concomitant medications, with a mean clinical follow-up of 32+/-2 months. Composite cardiovascular endpoints (all-cause mortality, non-fatal myocardial infarction, heart failure or angina pectoris hospitalization, stroke, coronary artery bypass grafting and percutaneous coronary interventions) were significantly more common in subjects with below median FMD of 10.7%, than above (11.8% vs 4.7%, p=0.007, respectively). Univariate analysis demonstrated that median FMD significantly predicted cardiovascular events [odds ratio (OR) of 2.78 and 95% CI 1.35 to 5.71 (p=0.003)]. After multivariate analysis including conventional CAD risk factors, median FMD was the best independent predictor of long-term cardiovascular adverse events [OR of 2.70 and 95% CI 1.16 to 6.32 (p=0.011)]. CONCLUSIONS Brachial artery median FMD independently predicts long-term adverse cardiovascular events in healthy subjects in addition to traditional risk factor assessment.
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Affiliation(s)
- Michael Shechter
- Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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Anti-cardiolipin antibodies and endothelial function in patients with coronary artery disease. Am J Cardiol 2008; 101:1094-7. [PMID: 18394439 DOI: 10.1016/j.amjcard.2007.12.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2007] [Revised: 12/09/2007] [Accepted: 12/09/2007] [Indexed: 11/23/2022]
Abstract
Endothelial dysfunction is considered an important marker in atherosclerosis, having a prognostic value. Antiphospholipid antibodies are considered prothrombotic and have recently been reported to be associated also with atherosclerosis. This study was conducted to investigate a possible association of endothelial dysfunction with various antiphospholipid autoantibodies in healthy subjects and patients with cardiovascular disease. In a single-center, prospective study, 2 groups were included. The study group included patients with cardiovascular diseases (coronary disease and/or cerebrovascular disease) and healthy subjects without apparent heart disease who were referred to the endothelial function laboratory for the assessment of endothelial function. Flow-mediated dilatation, which indicates endothelial function, and nitroglycerin-mediated vasodilatation, which indicates smooth-muscle function, were measured. The 2 groups were evaluated for autoantibodies, including anticardiolipin (aCL; immunoglobulin G [IgG], immunoglobulin M [IgM], and immunoglobulin A [IgA]), antinuclear antibody, anti-beta2-glycoprotein I (IgG, IgM, and IgA), and oxidized low-density lipoprotein. One hundred seven subjects were included in the study: 45 patients (42%) and 62 healthy controls (58%). Flow-mediated dilatation was significantly lower in patients compared with healthy controls (8.0 +/- 9.5% vs 8.0 +/- 13.5%, p = 0.012). In addition, nitroglycerin-mediated vasodilatation was nonsignificantly lower in patients than in healthy controls (8.0 +/- 13.4% vs 11.0 +/- 16.7%, p = 0.084). The mean levels of anti-beta2-glycoprotein I (IgG, IgM, and IgA), aCL (IgM and IgA), antinuclear antibody, and oxidized low-density lipoprotein were not different between groups. However, the mean level of IgG aCL was significantly higher in patients than in healthy controls. In conclusion, in accordance with previous reports of an association between aCL and atherosclerosis, patients with cardiovascular disease had endothelial dysfunction and elevated levels of aCL.
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Narita K, Murata T, Hamada T, Kosaka H, Sudo S, Mizukami K, Yoshida H, Wada Y. Associations between trait anxiety, insulin resistance, and atherosclerosis in the elderly: a pilot cross-sectional study. Psychoneuroendocrinology 2008; 33:305-12. [PMID: 18178323 DOI: 10.1016/j.psyneuen.2007.11.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 11/19/2007] [Accepted: 11/29/2007] [Indexed: 12/01/2022]
Abstract
Anxiety has been shown to be associated with cardiovascular disease. Atherosclerosis is responsible for the vast majority of cardiovascular events. Recent evidence is accumulating to show that insulin resistance (IR) plays a central role in determining the clinical manifestations of established atherosclerotic lesions. The current preliminary study aimed to investigate the associations between trait anxiety, IR, and atherosclerotic progression in healthy elderly subjects with normal fasting glucose and without metabolic syndrome. Thirty-five healthy elderly subjects (19 males and 16 females, mean age 64.5+/-4.7 years) were enrolled in this study. Trait anxiety was measured using a questionnaire corresponding to the trait anxiety scale taken from the State and Trait Anxiety Inventory. The homeostasis model assessment (HOMA-R) and plasma leptin-to-adiponectin ratio (L/A ratio), which are convenient IR indexes calculated from fasting blood sampling, were examined. As measurements of atherosclerotic progression, we performed two ultrasound methods, namely brachial artery flow-mediated dilation (FMD), an endothelial function assessment quantitatively reflecting the endothelium-dependent vasodilation responses following hyperemia, and measurement of carotid intima-media thickness (IMT). The severity of trait anxiety was positively associated with HOMA-R and L/A ratio, and negatively associated with the percent change of brachial artery FMD (%FMD). HOMA-R and L/A ratio were positively associated with carotid IMT, and L/A ratio was negatively associated with %FMD. These data showed the associations between trait anxiety, IR indexes and endothelial dysfunction or atherosclerotic progression. This pilot study, with a cross-sectional design, supports the promising role of IR for clarifying the pathophysiological mechanism by which anxiety contributes to an increasing risk of atherosclerosis.
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Affiliation(s)
- Kosuke Narita
- Department of Neuropsychiatry, University of Fukui, Eiheiji-cho, Fukui 910-1193, Japan
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London MJ. Beta blockers and alpha2 agonists for cardioprotection. Best Pract Res Clin Anaesthesiol 2008; 22:95-110. [DOI: 10.1016/j.bpa.2007.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Barsheshet A, Hod H, Shechter M, Sharabani-Yosef O, Rosenthal E, Barbash IM, Matetzky S, Tal R, Bentancur AG, Sela BA, Nagler A, Leor J. The effects of external counter pulsation therapy on circulating endothelial progenitor cells in patients with angina pectoris. Cardiology 2007; 110:160-6. [PMID: 18057883 DOI: 10.1159/000111925] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 05/06/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES External counter pulsation therapy (ECPT) offers symptomatic relief and improves ischemia in patients with refractory angina pectoris. We aimed to determine the effects of ECPT on circulating endothelial progenitor cells (EPCs). METHODS We prospectively studied 25 patients with angina pectoris treated with ECPT (n = 15) or receiving standard care (n = 10). The number of EPCs positive for CD34 and kinase insert domain receptor (KDR) was determined by flow cytometry and the number of colony-forming units (CFUs) was assessed in a 7-day culture, before ECPT and after 9 weeks. RESULTS ECPT improved anginal score from a median of 3.0 to 2.0 (p < 0.001). Concomitantly, ECPT increased EPC number from a median of 10.2 to 17.8/10(5) mononuclear cells (p < 0.05), and CFUs from 3.5 to 11.0 (p = 0.01). Flow-mediated dilatation was improved by ECPT from 7.4 to 12.2% (p < 0.001) and correlated with EPC-CFUs (r = 0.461, p = 0.027). The levels of asymmetric dimethylarginine were reduced by ECPT from 0.70 to 0.60 micromol/l (p < 0.01). In contrast, the same parameters did not change in the control group, before and after follow-up. CONCLUSIONS The present pilot study shows, for the first time, that ECPT is associated with increased number and colony-forming capacity of circulating EPCs.
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Affiliation(s)
- Alon Barsheshet
- Neufeld Cardiac Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
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Jin SM, Noh CI, Bae EJ, Choi JY, Yun YS. Impaired vascular function in patients with Fontan circulation. Int J Cardiol 2007; 120:221-6. [PMID: 17175041 DOI: 10.1016/j.ijcard.2006.09.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2006] [Revised: 08/10/2006] [Accepted: 09/24/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study was performed to evaluate the endothelial function in Fontan patients, and to investigate the associated factors which influence the endothelial function in these patients. METHODS Flow mediated dilatation (FMD) and nitroglycerin induced dilatation (NG) of the brachial artery, and intima media thickness (IMT) of common carotid artery (CCA) were measured in nonselected Fontan patients (n=44, age 5 to 29 years, median 14 years, 18 females) by means of high-resolution ultrasound according to the standard protocols. The results were compared to age and sex matched controls (n=25, age 5 to 27 years, median 13 years, 10 females). RESULTS Fontan patients presented significantly reduced FMD and NG compared with controls (FMD; 6.5+/-2.4 vs. 11.1+/-1.4%, p<0.001, NG; 13.3+/-5.2 vs. 19.4+/-6.2%; p=0.035). Twenty two percent of Fontan patients presented pure endothelial dysfunction, and 34% of patients presented combined endothelial and smooth muscle dysfunction. Although there was no correlation between FMD and IMT, Fontan patients presented increased carotid IMT (0.44+/-0.07 vs. 0.38+/-0.06 mm, p=0.008). In multivariate analysis, duration of exposure to chronic hypoxia was inversely correlated with FMD (p=0.117, hazards ratio=1.294, 95% confidence interval=0.938-1.786). There was higher FMD in patients receiving angiotensin-converting enzyme inhibitors (ACEi) compared with those not receiving ACEi (7.0+/-2.5 vs. 5.5+/-2.2%, p=0.069). CONCLUSIONS Endothelial dysfunction is more prevalent in Fontan patients compared with healthy controls, and the previous hypoxia is an independent factor. Although it is not statistically significant, those patients on treatment with ACEi seem to have better endothelial function.
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Affiliation(s)
- Seon Mi Jin
- Department of Pediatrics, Eulji Medical Center, Eulji University, 280-1 Hagyedong, Nowongu, Seoul 139-711, South Korea
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Narita K, Murata T, Hamada T, Takahashi T, Omori M, Suganuma N, Yoshida H, Wada Y. Interactions among higher trait anxiety, sympathetic activity, and endothelial function in the elderly. J Psychiatr Res 2007; 41:418-27. [PMID: 16494899 DOI: 10.1016/j.jpsychires.2006.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Revised: 12/28/2005] [Accepted: 01/03/2006] [Indexed: 10/25/2022]
Abstract
Negative psychological characteristics have been recognized as independent risk factors of cardiovascular disease (CVD). The purpose of this study was to evaluate the influence of depression and anxiety on cardiac autonomic function and endothelial function in healthy elderly subjects. Forty-six healthy elderly volunteers (mean age 60.8 years) were enrolled in this study. Cardiac autonomic function was assessed by spectral analysis of heart rate variability (HRV) with the head-up tilt test. Brachial artery endothelium-dependent flow-mediated dilation (FMD) was measured using high-resolution ultrasound. A significant positive correlation was observed between the State and Trait Anxiety Inventory (STAI)-trait score as a parameter of anxiety and HRV sympathetic modulation in the supine position (baseline), and a significant negative correlation between this score and the head-up-induced HRV sympathetic response from the baseline. The STAI-trait score also showed a significant negative correlation with the percent change of FMD (%FMD). Analysis using structural equation modeling showed that higher trait anxiety reduced %FMD via abnormalities of sympathetic activity. On the other hand, psychometric parameters of depression were not associated with any HRV component or %FMD. These results suggest that there are specific interactions among higher trait anxiety, abnormalities of sympathetic activity, and endothelial dysfunction. This finding may be useful in clarifying the pathophysiological mechanism by which anxiety is associated with increased risks for atherosclerosis and CVD.
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Affiliation(s)
- Kosuke Narita
- Department of Neuropsychiatry, Faculty of Medical Sciences, University of Fukui, Matsuoka-cho, Yoshida-gun, Fukui 910-1193, Japan
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Zhang Y, He X, Chen X, Ma H, Liu D, Luo J, Du Z, Jin Y, Xiong Y, He J, Fang D, Wang K, Lawson WE, Hui JCK, Zheng Z, Wu G. Enhanced external counterpulsation inhibits intimal hyperplasia by modifying shear stress responsive gene expression in hypercholesterolemic pigs. Circulation 2007; 116:526-34. [PMID: 17620513 DOI: 10.1161/circulationaha.106.647248] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Enhanced external counterpulsation (EECP) is a circulation assist device that may improve endothelial dysfunction by increasing shear stress. Chronic exposure of vascular endothelial cells and vascular smooth muscle cells to relatively high physiological shear stress has antiproliferative and vasoprotective effects. The present study hypothesizes that EECP inhibits intimal hyperplasia and atherogenesis by modifying shear stress-responsive gene expression. METHODS AND RESULTS Thirty-five male pigs were randomly assigned to 3 groups: high-cholesterol diet (n=11), high-cholesterol diet plus EECP (n=17), and usual diet (control; n=7). The coronary arteries and aortas were collected for histopathological study and immunohistochemical and Western blot analysis. The peak diastolic arterial wall shear stress during EECP increased significantly compared with before EECP (49.62+/-10.71 versus 23.92+/-7.28 dyne/cm2; P<0.001). Intimal hyperplasia was observed in the coronary arteries of the high-cholesterol diet group, whereas in animals receiving EECP, the intima-to-media area ratio was significantly decreased by 41.59% (21.27+/-10.00% versus 36.41+/-16.69%; P=0.008). Hypercholesterolemia attenuated the protein expression of endothelial NO synthase and enhanced the phosphorylation of extracellular signal-regulated kinases 1/2. EECP treatment alleviated these adverse changes. CONCLUSIONS EECP reduces hypercholesterolemia-induced endothelial damage, arrests vascular smooth muscle cell proliferation and migration, decreases proliferating cell nuclear antigen proliferative index, suppresses extracellular matrix formation, and eventually inhibits intimal hyperplasia and the development of atherosclerosis by increasing the arterial wall shear stress, which in turn activates the endothelial NO synthase/NO pathway and probably suppresses extracellular signal-regulated kinases 1/2 overactivation.
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Affiliation(s)
- Yan Zhang
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
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Shechter M, Ginsberg S, Scheinowitz M, Feinberg MS, Laron Z. Obese adults with primary growth hormone resistance (Laron Syndrome) have normal endothelial function. Growth Horm IGF Res 2007; 17:165-170. [PMID: 17320443 DOI: 10.1016/j.ghir.2007.01.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Revised: 01/15/2007] [Accepted: 01/16/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Classic Laron Syndrome (LS) is a recessive disease of insulin-like growth factor I (IGF-I) deficiency and primary growth hormone insensitivity, clinically characterized by dwarfism and marked obesity. The aim of the current study was to investigate the impact of long-term IGF-I deficiency on flow-mediated dilation (FMD) in 11 non-IGF-I-treated LS adults with long-term IGF-I deficiency who on stress echocardiography were found to have reduced cardiac dimensions and output, but normal left ventricular (LV) ejection fraction at rest and LV contractile reserve following stress. DESIGN Following an overnight fast we assessed percent improvement in endothelium-dependent FMD (%FMD) and endothelium-independent nitroglycerin (%NTG)-mediated vasodilation non-invasively in the brachial artery, using high resolution ultrasound in 11 non-treated adult patients with LS without known coronary artery disease, and compared them to 11 age- and sex-matched healthy controls. All subjects underwent symptom-limited exercise testing (Bruce protocol). RESULTS LS patients had a significantly higher body mass index (29+/-6 vs. 25+/-2 kg/m(2), p=0.04), lower low-density lipoprotein cholesterol (142+/-28 vs. 176+/-12 mg/dl, p=0.03) and a smaller mean brachial artery diameter (4.63+/-0.72 vs. 5.70+/-1.06 mm, p=0.01) compared to controls. However, brachial artery %FMD and %NTG were not significantly different between the LS patients and controls (13.1+/-6.2% vs. 15.4+/-5.2%, p=0.28 and 22.3+/-6.0% vs. 18.9+/-6.2%, p=0.30; respectively). Cardiac performance, assessed by exercise duration time and metabolic equivalents (METs), was significantly greater in control subjects than in LS patients (10.3+/-2.0 vs. 6.0+/-1.4 min, p<0.01 and 10.2+/-2.0 vs. 7.2+/-1.4 METs, p<0.01; respectively). CONCLUSIONS FMD was found to be within normal limits in non-IGF-I-treated adult patients with LS, despite congenital absence of IGF-I and obesity.
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Affiliation(s)
- M Shechter
- The Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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